APPLICATION #
Permitted Use
Special Exception
Variance
FLOOD PLAIN DEVELOPMENT PERMIT REQUEST
1.
APPLICANT
Name:
2.
Home Address:
Telephone:
Business Address:
Telephone:
OWNER(S) OF RECORD
Name:
3.
Home Address:
Telephone:
Business Address:
Telephone:
DESCRIPTION OF LAND PARCEL
Address:
Parcel zones as:
Map No.
4.
Total Area (acres):
Block No.
Parcel No.
(According to Town Assessor’s Map)
NAMES AND ADDRESSES OF ABUTTING PROPERTY OWNERS:
(If additional space is required, attach additional 8-1/2 x 11 sheets as necessary)
5.
DESCRIBE AND SHOW ACTIVITY TO BE PERFORMED WITHIN FLOOD PLAIN.
(Attach map showing any flood plain limits on entire parcel and specify activity to occur.)
APPLICATION #
6.
Attach copy of Corps of Engineers permit or statement from the Corps of Engineers
concerning the activity within the flood plain.
7.
GENERAL DATA CONCERNING FLOOD ELEVATION AS PER NAVD DATUM.
Flood elevation as per FEMA maps
a.
.
Structures
Elevation of lowest floor (including basement).
Elevation of floodproofing on structure.
b.
Fill
Elevation of highest elevation of fill.
Quantity of fill deposited in flood hazard area. Show calculations.
c.
Description of the extent to which any watercourse will be altered as a result of
proposed activity.
8.
9.
PERMITTED USES (Does not require permit if fill or structures are not involved.)
1.
Agricultural Use
2.
Industrial/Commercial Parking Areas – 3 vehicles or less
3.
Public/Private Recreational Uses
4.
Residential: Parking/lawns/gardens
SPECIAL EXCEPTIONS
a.
Type of Activity
Substantial improvement or addition to existing or accessory structure
Fill
b.
Supporting Detail
Structural Criteria: Show plan, profile, including Engineer’s Report of the
site improvements (see below):
1.
Indicate
Residential
Non-Residential
Replacement of existing structure
2.
Area of Addition/Improvement*
sq. ft. of addition.
*must be less than 25% of the area covered by the original structure*
APPLICATION #
3.
Fill criteria. Show map calculations and location of the following:
a.
That the volume of material added to the site below the base flood
elevation plus any volume displaced by the structure below the
base flood elevation and volume enclosed within the structure
below the base flood elevation is removed from an equal or lower
elevation than that upon which the proposed elevation.
b.
Indicate removed fill location.
c.
Show any elevations adjacent to the site parcel that are below or at
the base flood and/or property that may be affected by any grade
changes proposed on the property.
d.
Prepare a map to be submitted to FEMA to comply with the
National Flood Insurance Program for map revisions reflecting in a
conditional letter of map revision (LOMR).
4.
Engineer’s Report
a.
Professional Engineer’s certification pertaining to storage capacity
and flow capacity of affected watercourses during flooding
conditions. (Engineer may be required to provide calculations).
b.
Professional Engineer’s certification pertaining to floodproofing
methods identifying flood depths, pressures, velocities, uplifting
forces, etc.
5.
Area Use: Show map and identify any commercial, residential or
industrial area within the base flood zone that is to be used for parking,
drives, loading areas or other improvements.
10.
VARIANCE DETAIL
Lot of Record Requirement: List the recorded date when the parcel became a lot of record.
Describe reason for variance request. If related to a historic structure, provide information
supporting its listing in the National Registry of Historical Places, the State Inventory of
Historic Places, or other locally-adopted historic district.
(If additional space is required, attach additional 8-1/2 x 11 sheets as necessary)
APPLICATION #
State the effects as a result of increased flooding: access to the parcel as a result of
development, threats to public safety; creation of nuisances; or extraordinary expenses.
(Also see Sec. 3-43(2) of Flood Plain Ordinance). Note: Supporting documentation from
Professional Engineer required on any statements concerning flooding.
State neighborhood characteristics and any effect the project may have concerning change.
All data supplied must be certified by a Professional Engineer registered in State. Any
elevations or property lines shown shall be of A-2 standards certified by a land surveyor,
registered by the State.
CERTIFICATION
The undersigned warrants the truth of all statements contained herein and in all supporting documents to the
best of their knowledge and belief.
Applicant’s Signature
Owner’s Signature